The Canadian birth place study: examining maternity care provider attitudes and interprofessional conflict around planned home birth

Abstract

BackgroundAvailable birth settings have diversified in Canada since the integration of regulated midwifery. Midwives are required to offer eligible women choice of birth place; and 25-30% of midwifery clients plan home births. Canadian provincial health ministries have instituted reimbursement schema and regulatory guidelines to ensure access to midwives in all settings. Evidence from well-designed Canadian cohort studies demonstrate the safety and efficacy of midwife-attended home birth. However, national rates of planned home birth remain low, and many maternity providers do not support choice of birth place.MethodsIn this national, mixed-methods study, our team administered a cross-sectional survey, and developed a 17 item Provider Attitudes to Planned Home Birth Scale (PAPHB-m) to assess attitudes towards home birth among maternity providers. We entered care provider type into a linear regression model, with the PAPHB-m score as the outcome variable. Using Students’ t tests and ANOVA for categorical variables and correlational analysis (Pearson’s r) for continuous variables, we conducted provider-specific bivariate analyses of all socio-demographic, education, and practice variables (n=90) that were in both the midwife and physician surveys.ResultsMedian favourability scores on the PAPHB–m scale were very low among obstetricians (33.0), moderately low for family physicians (38.0) and very high for midwives (80.0), and 84% of the variance in attitudes could be accounted for by care provider type. Amount of exposure to planned home birth during midwifery or medical education and practice was significantly associated with favourability scores. Concerns about perinatal loss and lawsuits, discomfort with inter-professional consultations, and preference for the familiarity of the hospital correlated with less favourable attitudes to home birth. Among all providers, favourability scores were linked to beliefs about the evidence on safety of home birth, and confidence in their own ability to manage obstetric emergencies at a home birth.ConclusionsIncreasing the knowledge base among all maternity providers about planned home birth may increase favourability. Key learning competencies include criteria for birth site selection, management of obstetric emergencies at planned home births, critical appraisal of literature on safety of home birth, and inter-professional communication and collaboration when women are transferred from home to hospital.

Pregnancy related anxiety and general anxious or depressed mood and the choice for birth setting: a secondary data-analysis of the DELIVER study

“…Also, positive attitudes of midwives regarding home birth and a critical attitude to hospital birth for non-medical reasons have been found to explain some of the variance found in home birth rates across Dutch midwifery practices [32]. Positive attitudes towards home births among UK maternal caregivers in general, are associated with the amount of experience and confidence in managing obstetric risks in home births and with maternal caregivers’ beliefs about safety of home births [33]. Other interesting outcomes related to preferred place of birth and risk perception have been found as well.…”

Obstetrician Attitudes, Experience, and Knowledge of Planned Home Birth: An Exploratory Study

“…Additionally, since 9–13 percent of women who intend to deliver at home require hospital transfer where inter‐professional communication is a determinant of patient outcomes, it is critical to learn more about provider beliefs . A Canadian study found that 84 percent of the variance in attitudes toward home birth could be accounted for by type of maternity provider, with obstetricians having the least favorable attitudes, midwives having the most favorable attitudes, and family practitioners falling in between . Another paper describing results from the same study found that midwives generally believed home births to be safe, while physicians were diametrically opposed .…”

Unplanned Out-of-Hospital Birth—Short and Long-Term Consequences for the Offspring

“…Similarly to previous publications [1,4], we found the risk of perinatal mortality to be up to 3 folds higher in out-of-hospital deliveries compared with in-hospital deliveries. While elective home birth as a pre-planned event attended by trained midwives and physicians may have comparable outcomes to planned in-hospital birth [10][11][12][13], the accidental, un-intended out-of-…”